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Wasa Adoption Application
WASA ADOPTION APPLICATION
Date
MM slash DD slash YYYY
Applying For
Name of Animal
Species
Description
Age
Special Needs
Applicant's Information
Full Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
Email
*
Age
Household Information
Where Do You Live?
House
Condo/Apt.
Mobile Home
Student Housing
Military Housing
(Please indicate one)
Neighborhood
Urban
Suburban
Rural
How long at your present address?
Do You Own Your Own Home?
Yes
No
If yes, please provide proof of ownership
Do you rent?
Yes
No
Landlord's Name
Landlord's Phone Number
Are you planning to move within the next year?
Yes
No
If yes, what are your plans for your companion animal when you move?
If you decide to move in the future, what will you do with your companion animal?
What provisions have you made for your companion animal in the event of your illness or death?
How many adults in your home?
What are their ages?
Are there children in your home? YesNo
Yes
No
If yes, how many and what are their ages?
Are all members of your household aware of your plans to adopt an animal? YesNo
Yes
No
Are any members of your household allergic to animals?
Yes
No
Where will your companion animal sleep?
How many hours will your companion animal be alone?
Who will be responsible for the animal?
Does anyone in your household smoke? YesNo
Yes
No
If yes, where?
Do you have any health conditions which could restrict your ability to care for an animal?
Yes
No
If yes, please describe
Vacation
How often do you go on vacation?
Who will care for your companion animal when you go on vacation?
Employment
Employer
Occupation
How long at your present job?
Can you be contacted at your job?
Yes
No
If yes, work phone #
Other Animals
Do you have cats?
Yes
No
If yes, How Many?
Do the cats live strictly indoors?
Yes
No
Are the cats declawed?
Yes
No
Do you have dogs?
Yes
No
If yes, How many?
Do dogs live indoors?
Yes
No
Other animals?
Yes
No
If yes, How many?
Describe living conditions of other animals
Are all animals in your household spayed/neutered?
Yes
No
Name of Veterinarian
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
If no companion animals at this time, have you had any in the past 8 years?
Yes
No
If yes, what happened to them?
References
Please list people other than family who you have known for at least 5 years.
Name
First
Last
Phone Number
Name
First
Last
Phone Number
Name
First
Last
Phone Number
Questions
Why do you want to adopt an animal?
What type of personality are you looking for?
(If applicable) Have you ever had a special needs animal before?
Yes
No
If yes, describe
If necessary, how will you discipline the animal?
I hereby certify that all information supplied by me on this application is true.
Signature
Date
MM slash DD slash YYYY
Δ